NU272 Week 5 EAQ Evolve Elsevier: Nursing Skills

Which instruction is important for the nurse to include in discharge teaching for a client who has to perform intermittent urinary self-catheterization? o "Wear sterile gloves when doing the procedure." o "Wash your hands before performing the procedure." o "Perform the self-catheterization every 12 hours." o "Dispose of the catheter after you have catheterized yourself."

o "Wash your hands before performing the procedure." · To prevent transferring organisms to the urinary system, the client is taught to wash his or her hands thoroughly with soap and water before inserting a clean catheter. Sterile gloves are not required for this procedure in the home care setting. Every 12 hours is too long of a time frame between catheterizations. The client should be taught to recognize when self-catheterization is needed and develop a 2- to 3-hour catheterization schedule. Some home care settings may require the client to clean and reuse catheters.

Which personal protective equipment will the nurse plan to wear when providing central venous access device site care? o Double sterile gloves and gown o Mask and sterile gloves o Hair cap and sterile gloves o Gown and double gloves

o Mask and sterile gloves · A mask will protect the catheter insertion site from droplet and airborne microorganisms emanating from the nurse, and sterile gloves will protect the insertion site from contact with microorganisms on the nurse's hands. Double gloves and a hair cap are not needed. Gown use is based on facility protocol.

The nurse is preparing to change a client's dressing. For which reason would the nurse use surgical asepsis? o Keeps the area free of microorganisms o Confines microorganisms to the surgical site o Protects self from microorganisms in the wound o Reduces the risk for growing opportunistic microorganisms

o Keeps the area free of microorganisms · Surgical asepsis means that practices are employed to keep a defined site or objects free of all microorganisms. Confining microorganisms to the surgical site and protecting self from microorganisms in the wound apply to personal protective equipment and medical asepsis. Reducing the risk for growing opportunistic microorganisms applies to medical asepsis.

Which is the recommended length of insertion of the enema tube in a child of 3 years? o 1 to 2.5 cm o 5 to 7.5 cm o 7.5 to 10 cm o 2.5 to 3.7 cm

o 5 to 7.5 cm · For a 3-year-old child, the recommended length of insertion of the enema tube is 5 to 7.5 cm. The length of 1 to 2.5 cm is incorrect, because it is too small. Even the insertion length of the enema tube used in infants is longer than this. For infants, the length of insertion of the enema tube should be 2.5 to 3.7 cm. For adolescents and adults, this length is 7.5 to 10 cm.

The nurse is preparing to administer an oil-retention enema and understands that it works primarily by which action? o Stimulating the urge to defecate o Lubricating the sigmoid colon and rectum o Dissolving the feces o Softening the feces

o Lubricating the sigmoid colon and rectum · The primary purpose of an oil-retention enema is to lubricate the sigmoid colon and rectum. Secondary benefits of an oil-retention enema include stimulating the urge to defecate and softening feces. An oil-retention enema does not dissolve feces.

A home health nurse teaches a family member to cleanse a client's wound and apply a sterile dressing. Which action by the family member during a return demonstration indicates the need for additional teaching? o Placing the old dressing in a plastic bag o Changing the dressing without wearing a mask o Donning nonsterile gloves for removing the old dressing o Using a back-and-forth motion with the same gauze while cleaning the wound

o Using a back-and-forth motion with the same gauze while cleaning the wound · After each swipe, sterile gauze should be discarded, and a new sterile gauze should be used for the next swipe. The other options are correct. Placing the old dressing in a plastic bag confines the soiled dressing to a leak-proof bag and prevents contamination of the environment or others. A mask is not necessary. Nonsterile gloves are acceptable for dressing removal because the dressing is contaminated; sterile gloves may be required for dressing application.

A high cleansing enema is prescribed for a client. Which is the maximum height at which the container of fluid would be held by the nurse when administering this enema? o 30 cm (12 inches) o 46 cm (18 inches) o 51 cm (20 inches) o 66 cm (26 inches)

o 46 cm (18 inches) · For a high colonic enema to be effective, the fluid must extend higher in the colon. If the height of the enema fluid container above the anus is increased, the force and rate of flow also increase. A height of 46 cm (18 inches) is correct. A height of 30 cm (12 inches) is too low for a cleansing enema. Heights of 51 cm (20 inches) and 66 cm (26 inches) are too high and may cause mucosal injury.

Which basic principles of surgical asepsis must the nurse consider when changing the dressing of a child with severe burns? Select all that apply. One, some, or all responses may be correct. o A paper field must remain dry to be considered sterile. o Sterile items held below the waist are considered sterile. o A 1-inch (2.5 cm) border around a sterile field is considered contaminated. o Sterile objects in contact with clean objects are considered contaminated. o A fenestrated drape is not considered sterile

o A 1-inch (2.5 cm) border around a sterile field is considered contaminated. o Sterile objects in contact with clean objects are considered contaminated. o A paper field must remain dry to be considered sterile. · Once a sterile paper field becomes wet it allows microorganisms on the surface of the table to contaminate the field. A 1-inch (2.5 cm) border around the outer edge of a sterile field is considered contaminated because the edges touch the table. Once a sterile object comes into contact with any object that is not sterile, it is no longer considered sterile. Sterile objects below the waist are considered contaminated. A fenestrated drape may be considered sterile as long as it has not been contaminated.

The family of an older adult reports to the nurse manager that the primary nurse failed to obtain a signed consent before inserting an indwelling catheter. Which rationale would the nurse manager consider before responding? o Procedures for a client's benefit do not require a signed consent. o Clients who are aphasic are incapable of signing an informed consent. o A separate signed informed consent for routine treatments is unnecessary. o A specific intervention without a client's signed consent is an invasion of rights.

o A separate signed informed consent for routine treatments is unnecessary. · This is considered a routine procedure to meet basic physiological needs and is covered by a consent signed at the time of admission. The need for consent is not negated because the procedure is beneficial. This treatment does not require special consent.

Which technique would the nurse use to maintain surgical asepsis? o Change the sterile field after sterile water is spilled on it. o Put on sterile gloves and then open a container of sterile saline. o Place a sterile dressing no more than half an inch from the edge of the sterile field. o Clean the surgical area with a circular motion, moving from the outer edge toward the center

o Change the sterile field after sterile water is spilled on it. · A sterile field is considered contaminated when it becomes wet. Moisture can act as a wick and allow microorganisms to contaminate the sterile field. The outsides of containers and packages are not considered sterile and sterile gloves are considered contaminated when touching either of these items. Items on the sterile field should be no less than 1 inch from the outer border or edge of the sterile field; any less is not considered sterile. Surgical areas or wounds should be cleaned from the inside edges to the outside edges to prevent recontamination.

Which procedure is used to verify placement of a newly inserted central venous access device (CVAD)? o Chest x-ray o Flushing the line with heparin o Withdrawing blood to ensure patency o Chest fluoroscopy

o Chest x-ray · The insertion of a central venous catheter (CVC) into the subclavian vein can result in a pneumothorax, which would be seen on a chest x-ray. Indications of a pneumothorax before the chest x-ray would include shortness of breath and anxiety. If the chest x-ray is negative for pneumothorax, the CVC line may be used. The central line should not be flushed until placement is verified. Blood withdrawal is utilized once placement is verified, but is not used to verify initial placement. Fluoroscopy may be used during placement in certain settings, but not for placement verification.

During a tap water enema, a client reports abdominal cramps. Which action would the nurse take? o Clamp the tubing and allow the client to rest. o Reassure the client and continue the irrigation. o Pinch the tubing so that less fluid enters the colon. o Raise the irrigating container to complete the irrigation quickly.

o Clamp the tubing and allow the client to rest. · Rapid instillation of fluid into the colon may cause abdominal cramps. By clamping the tubing, the nurse allows the cramps to subside so the irrigation eventually can be continued. Emotional support will not interrupt the physical response of abdominal cramps. Although pinching the tubing would lessen the fluid entering the colon and raising the irrigating container to complete the irrigation quickly might reduce the force of the fluid, neither of these will eliminate the flow of fluid completely. Increasing the force of flow will increase abdominal cramps.

The nurse uses the same pair of gloves to remove a soiled dressing and to apply a new sterile dressing. Another nurse is observing the dressing change procedure. Which initial action would the observing nurse take? o File an incident report. o Discuss the incident with the nurse. o Offer to demonstrate the proper technique. o Report the individual to the nursing supervisor

o Discuss the incident with the nurse. · Discussing the incident with the nurse is the initial action. The nurse should understand that the technique is not safe and discussing the incident with the nurse provides an opportunity for the offending nurse to correct the technique being used. The dressing should be changed immediately and correctly; the priority is to protect the client. Filing an incident report depends on the policy of the institution and might be done later. Offering to demonstrate the proper technique may or may not be done by the observing nurse; if so, it should be done later. Reporting the individual to the nursing supervisor depends on the policy of the institution and might be done later.

The nurse is assigned to change a central line dressing. The agency policy is to clean the site with povidone-iodine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede povidone-iodine in a dressing change. In addition, an article in a nursing journal stated that a new product was a more effective antibacterial than alcohol and povidone-iodine. The nurse has a sample of the new product. How would the nurse proceed? o Use the new product sample when changing the dressing. o Cleanse the site with alcohol first and then with povidone-iodine. o Cleanse the site with the new product first and then follow the agency's protocol. o Follow the agency's policy unless it is contradicted by a primary health care provider's prescription

o Follow the agency's policy unless it is contradicted by a primary health care provider's prescription · Agency policy determines procedures; if the procedure is out of date or problematic, the nurse would contact the primary health care provider for a change in the prescription. The nurse cannot use another product without a primary health care provider's prescription. The nurse will be risking liability if agency policy is not followed, unless the prescription is changed by the primary health care provider.

When donning sterile gloves, how would the nurse glove the second hand? o Grasp the finger portion of the second glove and lift; then insert remaining hand into glove. o Insert gloved fingers under cuff of second glove and lift glove; then slide ungloved hand into glove. o Using your gloved hand, grasp the folded edge of the second glove with two fingers and place glove on nondominant hand. o Don glove on nondominant hand first, then hold the glove away from body and below waist to slide glove on.

o Grasp the finger portion of the second glove and lift; then insert remaining hand into glove. · Sterile gloves can only be handled by sterile equipment, or they are contaminated. The sterile glove that has been donned may touch under the cuff on the sterile surface as the nondominant hand is inserted. The sterile glove may not touch the inside of the glove. Donning a sterile glove and placing below the waist means contamination, because under the waist or in back is contaminated. Grasping by the cuff (folded edge) means the inside of the glove has been touched.

A client is scheduled for a colonoscopy, and the health care provider prescribes a tap water enema. In which position should the nurse place the client during the enema? o Left Sims o Back lying o Knee-chest o Mid-Fowler

o Left Sims · To take advantage of the anatomical position of the sigmoid colon and the effect of gravity, the client should be placed in the left Sims or left side-lying position for the enema. Back lying, knee-chest, or mid-Fowler positions do not facilitate the flow of fluid into the sigmoid colon by gravity.

The client reports abdominal cramping while undergoing a soapsuds enema. Which action would the nurse take? o Immediately stop the infusion. o Lower the height of the enema bag. o Advance the enema tubing 2 to 3 inches (5-7.5 cm). o Clamp the tube for 2 minutes and then restart the infusion.

o Lower the height of the enema bag. · Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the tube for several minutes and then restarting the infusion may be attempted if slowing the infusion does not relieve the cramps.

A client is admitted with extensive bone and soft-tissue injuries to the leg and sterile dressings are applied. Two days later, when removing the dressings, the nurse finds that one of the dressings has adhered to tissue in several places. Which action would the nurse take to loosen the dressing? o Apply diluted hydrogen peroxide. o Pull with gentle but steady traction. o Soak the area in a solution of Betadine. o Moisten the dressing with sterile saline

o Moisten the dressing with sterile saline · Sterile saline will soften the dried exudates adhered to the dressing, limiting tissue damage when the dressing is removed. The use of hydrogen peroxide can be irritating to the tissues. Pulling off the dressing with steady traction may be painful and cause unnecessary tissue damage. The use of Betadine to remove a dressing is not recommended.

Which evidenced-based nursing intervention links to reducing catheter associated urinary tract infections (CAUTIs) in clients requiring long-term indwelling catheters? o Perform catheter care twice a day. o Replace the catheter on a routine basis. o Administer cranberry tablets three times a day. o Administer prophylactic antibiotics twice a day for the duration of the catheter placement

o Perform catheter care twice a day. · A biofilm made up of bacteria develops on long-term indwelling catheters. The best way to eliminate this biofilm is to perform routine perineal hygiene daily. The efficacy of cranberry tablets in decreasing the frequency of urinary tract infections has not been established. Antibiotic therapy may increase the growth of microbes within the biofilm.

A client begins to have difficulty breathing 30 minutes after the insertion of a subclavian central line. Which would the nurse do first? o Raise the head of the bed. o Apply oxygen. o Assess breath sounds. o Call the primary health care provider requesting a chest x-ray.

o Raise the head of the bed. · The priority is to assist breathing. Raising the head of the bed is the least invasive and first action. Assessing for diminished breath sounds and applying oxygen are important but should be done after raising the head of the bed. In addition, requesting a chest x-ray, if not already done, is appropriate, but the priority is to immediately perform nursing interventions that will promote ventilation.

Which action would the nurse take when a client reports pain and burning at a peripheral intravenous (IV) site after the nurse has flushed the saline lock with normal saline? o Remove the IV catheter and restart the saline lock in another site. o Document the findings per protocol and reassess the site in 8 hours. o Flush the IV catheter and saline lock again vigorously with normal saline. o Change the dressing and apply a new clean dressing per IV care protocol.

o Remove the IV catheter and restart the saline lock in another site. · The client's report of pain and burning at the site indicates that the tip of the catheter is no longer in the vein and the client needs removal of the current catheter and a new IV access site. Documenting the findings and then reassessing the site in 8 hours would leave the client with no IV access. Flushing vigorously will lead to more pain as more saline is pushed into the infiltrated site. Changing the dressing would leave the client without a patent IV access.

During administration of an enema, a client experiences intestinal cramps. Which action would the nurse take? o Discontinue the procedure. o Instill the fluid at a slower rate. o Lower the height of the container. o Stop the fluid until the cramps subside.

o Stop the fluid until the cramps subside. · Administration of additional fluid when a client reports abdominal cramps adds to discomfort because of additional pressure. By clamping the tubing for a few minutes, the nurse allows the cramps to subside, and the enema can be continued. Cramps are not a reason to discontinue the enema entirely; temporary clamping of the tubing usually relieves the cramps, and the procedure can be continued. Slowing the rate decreases pressure but does not reduce it entirely. Lowering the height of the container will reduce the flow of the solution, which will decrease pressure but not eliminate it entirely.

At which site would the nurse obtain a sterile urinalysis from a client with an indwelling catheter? o Tubing injection port o Distal end of the tubing o Urinary drainage bag o Catheter insertion site

o Tubing injection port · The appropriate site to obtain a urine specimen for a client with an indwelling catheter is the injection port. The nurse would clean the injection port cap of the catheter drainage tubing with appropriate antiseptic, attach a sterile 5-mL syringe into the port, and aspirate the quantity desired. The nurse would apply a clamp to the drainage tubing, distal to the injection port, not obtain the specimen from this site. Urine in the bedside drainage bag is not an appropriate sample, because the urine in the bag may have been there too long; thus a clean sample cannot be obtained from the bag. The client's urine will be contained in the indwelling catheter; there will be no urine at the insertion site.